Personal and personnel requirements (local factors)

Practitioner demeanor is fundamental to all patient care. Urologists are among the greatest innovators in medical sciences, and have seen and helped lead great change in surgical practice so far this century and last. As a specialty group, many are proud of the nature of the specialty to troubleshoot issues with robots, lasers, endoscopic tools, scopes, and all sorts of digital and analog tools used in practice. The same mentality is required in telehealth. The same openness and cautious evidence-based approach to change is required. Whether that be, adapting new practice procedures and protocols as becomes necessary, evolving to run hybrid clinics, or moving toward sessions which are entirely offered by telehealth. The same dynamism that allows urologists to maintain a diverse skillset from open to minimally invasive surgical skills, from andrology to oncology, fertility to reconstruction, is what is required to adopt telehealth and begin adapting one’s practice to incorporate telementoring, telediagnosis tools, and telemonitoring tools.

In much the same way, it is imperative to have a similar culture across one’s practice. Having coworkers and colleagues willing and able to incorporate something new and sometimes challenging, is equally as important. Being able to welcome new challenges, and using telepresence and digital tools to help improve patient care, is a significant change, and time and training required for staff to gain confidence in their use, will pay dividends and give greater confidence to patients who deserve competent and confident care. Technology can and should make our lives better and safer. But its use often requires careful and considered planning to ensure that everything from the cameras, microphones, digital records, digital patient and practice schedules, and digital payment systems are maintained, secured, and properly used. In many ways, these are reflected by the culture of the healthcare organisation or urology practice, and take time to develop.

Lobbying for better access (national/state-level factors)

While many advocates of telehealth will espouse, the platform allows greater access to better health. However, this is only the case for those who are willing and able to use such portals, and perhaps more critically, for those that can afford and have access to appropriate devices and providers of cellular and internet access. One should not assume that because someone lives in a large metropolitan area or a “developed” nation, that they have access to adequate broadband internet. The average connection speeds in 2020 were ∼42Mbits/s in the United States and 103Mbits/s in the European Union (EU). While these are adequate for videoconferencing and a video consult, remember that gigabit connections were expanding in these regions before 2020, and that these outliers will buoy those average values.

While access to healthcare has long been a priority policy point for healthcare advocates, access to reliable, high-speed internet and suitable devices to conduct telehealth visits, becomes synonymous with access, in a world where telehealth becomes the norm. While some may see this as complicating the issue of access to healthcare, it should be remembered that health access was always complicated, and that with these few infrastructure pieces in place, access to the whole array of health services can become a lot simpler. Consider a patient who needs to see their general practitioner, ophthalmologist, audiologist, podiatrist, occupational therapist, and physiotherapist. On top of the complexity to manage the scheduling, the patient is encumbered with the logistics of getting from one department to the next on time, and from one building to the other, and often these are geographically dispersed practice locations. If one considers that ∼10% of the US population >18 years of age report some mobility difficulty, and according to the CDC, 26% of adults in the United States of America report some type of disability, one now can appreciate that attending medical visits in person can quickly become a near full-time occupation for those who need multidisciplinary medical care ( ). It is therefore important for healthcare workers and practitioners to lobby and promote for better access for patients, and also for easier access for physicians to practice telehealth, to offer alternative routes to access care, and unencumber this significant proportion of the patient population. That is not to say there should be no regulation, and as with most things in the age of the internet, consumers and healthcare providers require protections from those who would seek to exploit such systems. It should also be remembered that while everyone should have access to adequate and sufficient healthcare, that healthcare is not a consumer product. “Productified” health is not healthcare, and many consider it exploitative of patients and physicians and to the detriment of societal well being.

What urologists should know about spectrum allocation?

While some of this may seem like historical miscellany, it is important to understand the context of spectrum allocation for a number of reasons. First, the bandwidths and frequencies are not unlimited. Many who listened to terrestrial radio are familiar with two radio stations of a similar frequency, interfering with each other, this is known as tropospheric ducting. This is when signals bleed into one another. To avoid this, and because bandwidths are finite, allocation of bandwidth must be respected and may require regulation to avoid interference. In the early part of the 21st century, governments in the EU and United States allocated the finite frequency spectrum, following an auction. In Europe, over 20 years ago, over $100 billion was collectively paid for these frequency spectrum allocations by private industry.

The allocations in the United States are particularly notable, as the entire spectrum was not auctioned. (This is likely the case elsewhere also; however, more information is available on the United States). A significant part of the spectrum was allocated to the US Department of Defense. With growing saturation of commercially available bandwidths, lobbyists have pushed for the Department of Defense to cede or share some of their bandwidths to private industry. Separately there have been discussions about cooperation of the Department of Defense sharing some bandwidth for medical applications, as for a period of time, only they had sufficient bandwidth available, which was reliable enough, secure enough, and with low enough latency to facilitate entirely remote robotic-assisted surgery.

In 2020, the US Department of Defense published an Electromagnetic Spectrum Superiority Strategy. This is a plan to ensure that the United States maintains its military advantages in the electromagnetic spectrum. The strategy has three main goals: to control the electromagnetic spectrum, to deny adversaries the ability to use the electromagnetic spectrum, and to protect the United States from electromagnetic threats. The strategy also includes a number of initiatives to improve the United States’ ability to operate in the electromagnetic spectrum, including developing new technologies and improving training and education. What is similar for defense, as it is for healthcare, is that nearly every form of communication used today in hospitals and by healthcare workers is wireless and leverages the electromagnetic spectrum. The electromagnetic spectrum encompasses all possible frequencies of electromagnetic radiation, from low-frequency radio waves to high-frequency gamma rays. While frequencies above 300 GHz include infrared light, visible light, ultraviolet light, and X-rays, frequencies at 300 GHz and below are used to transmit information for cell phones, television, radio, satellite communications, Global Positioning Systems, Bluetooth communication as well as radio frequency identification chips, commonly used on ID badges, for swipe cards to access buildings and to unlock cars and devices.

For many of the same reasons that the US Department of Defense sees it as a strategic imperative that they have unrestrained, unfettered, and exclusive access to an entire block of the spectrum, one can see the importance for healthcare to have a similar level of access. Commercial advancements proliferating wireless devices and services will continue to erode the capacity for healthcare to utilize the finite resource that is the electromagnetic spectrum. As the airwaves become saturated, how can access be equitably distributed? If healthcare delivery (via telehealth and wearable devices and sensors) will rely upon access to the available electromagnetic spectrum, should the provision of a pacemaker come with a monthly plan? Will those providing connected health have to compete with discretionary consumer spending categories from “connected accessories” from car manufacturers, to cell phone and computer companies, television networks, and retail, social media, and search behemoths, for the limited space available?

The future proliferation of electromagnetic spectrum-dependent systems in health will include almost all elements of healthcare, from diagnosis, monitoring, population health surveillance to treatment and rehabilitation. It is incumbent upon those planning for future health systems, public health officials, healthcare systems, and all stakeholders in healthcare, to advocate and ensure sustained future and equitable access for healthcare systems. And much like the practice of evidence-based medicine, it is also imperative that those in healthcare understand the risks and benefits, the consequences of its use, and any potential adverse effects, arising from the use of such products, devices and services. We will discuss this in a separate section later in this chapter.

What urologists currently use the electromagnetic spectrum for in everyday practice?

Different parts of the spectrum serve different health purposes. X-rays have been in routine use in medical care for over a century, being used 6 months after Roentgen’s discovery to identify bullets in wounded soldiers. Other segments of the spectrum are not as often considered for their utility in medicine, yet those uses are no less essential for healthcare to function. For example, radio waves are still utilized by many health systems using pager systems. They still have advantages over cellphones as they can travel (relatively) long distances and pass through solid objects like buildings and trees, and even receive messages in hospital basements and through lead-lined walls in radiology departments. Microwaves have higher data rates than radio waves and are often used for satellite communications, internet access, and other communications. Microwave energy has also been used in medical treatments for over 40 years, and there are a number of applications in use including tissue ablation, and also in applications such as sterilization. Infrared is of course closely associated with heat sources, and is widely applied in noncontact thermometers, and in screening equipment in waiting rooms and entrances to facilities. Infrared light can be used to help treat conditions such as pain and is widely used as part of rehabilitation therapy, and by others to aid in wound and tissue healing. It has also been adopted in some surgical systems to help visualize blood vessels and tissue perfusion, with the ability to discern relative levels of perfusion and blood flow, and so has applications from disciplines as varied as reconstructive surgery and cancer surgery, to stroke care and vascular surgery. Gamma rays are also familiar to the practicing urologist, as many will have had questions from patients on the “gamma-knife” surgeries performed by radiation oncology colleagues. Gamma rays have the shortest wavelengths and greatest energy on the electromagnetic spectrum, and owing to their properties, are widely used in tissue destruction (or radiation therapy). Gamma rays when administered in sufficient doses are also lethal to prions, viruses, bacteria, and other microorganisms, and so are also used to sterilize medical equipment. Gamma rays are also used in nuclear medical imaging techniques such as positron emission tomography (PET) imaging.